22203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification PER2WT NO.
Building .- o6 'A��-D�S� 2 2 2 0 3
p
CITYOFCUPERTINO-BUILDING DIVISION7Li ^IG _ C�
V7}Hf;(7G1� CO //I APPLICATION /PERMIT d f
/VBU LDING-FlECTR CALPLUMBINGMEC AMCAL CATEGORY CONTROLp
rcMten/Gglneer: Lk. o'
QTY ELECTRIC PERMIT FEE s� BUILDING PERMIT INFO
Add. PEthITISSUANCE ,Za DD IQq Ik1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L(-I �J
I hereby affirm that l am licensed under provislma of Chapter9(commenc APPLIANCESRFSIDENTIAL JOB DESCRIPTION -
ingwith5enlon 7o00)of Dlvtsiun3otthe BusineumdProfeskons Code,and my
license is in full force and effect. PANELS 'nn( rn
License Class Lk.N � Ve /' cl.(r
Date Contractor UPT002DO NU
IS
ARCHITECPS DECLARATION
PS
97. I understand my plans shall W used ns public records. OVERIODOAMPS SQ.F7.FLOOR AREA $/SQ.FT.
Q D
a Licensed Professional SIGNS ELECTRICAL C IN
VIA LG
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISE1 ,
F, 7 Thereby a(OrmtWl]am aemptfromthe Contranorb Llrenae law for the U
700.. following reactor.(Sect7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST. R
ZS county which requlresa permit to rowsrun,alter,improve,demnlish,or repair
Q anystmnurc isrc
priorto its maance,also quircstheapplm
cafw such permit to POWER DEVICES 5 g /
U file a signed statement that he is B¢ved pursuant to the provisions of the
6 Contractors nlaw(CW 9(com)ortha withxemptthereof Divi. ��ALUApON
Q�QQ assask
kon3ofthe BusinessimeaeLnd ProfessionsCoate) heis th Semon7000tromarW SWIMMINGPOOLELECfRBZ Q OO
" the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES ♦ 0
`u1r6� applicant fora permit subjects the applicant to a civil penalty of not more than
a 2 five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT.
.-�n ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
k7a compematlon,wllldothe work and the struaturet+not(romiledir offered for
sale(Sec.7016,Busbiessand Professions Code:The Contramofs License law
$$ don not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who doessuchwork himself orthrough his own employees,provided that such
Improvements are not Intended oroffercd for sale.IThowever,the Wildingor TOTAL: 3 90
improvement issoldwithln oneyearofcompinlon,the owner-bullderwill have
the�urden of proving that he did not build or lmpmve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract.to construct the perfect(Sec.7044,Business and Professions Code:
The Contmnor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptojecta with a ALTER-DRAIN&VENT-WATER(EAT
cgPt[+ctorte)1lcenxd pursuant ro the Contnmor's Llcenu Law. FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason BACK FLOW PROTCCT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
ranee RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI IDOL TAX Y N
❑I hereby affirm that I have a certNcete of content to self-Insure,ora RECUT N
certificate of Workers'Compensation Inks w a certified copythemof(Sec. GAS FA.SYSTEM-11NCA OUTLETS PARKFE Y N
3800,lab C) ftECEPT N
Ce y
Policy I GAS EA.SYSTEM.OVER 4(EA)
BUILDING DIVISION FEES
Certified copy is hereby burnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certilled copy V filed(fled with the my Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAh7fARY-5717RM EA 200FT Date Recel t#
ti
Thlsse on need nae W completed if the mit b perfw on hundred dollars
($100)orless.) WATER[iEA77R W/VENT/E.ECTR ENERGYFEE Y_ N_
I certify that In the performance of thework IorwhIch this permit 1s Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
OZ Applicant NEW RE DENTIALPMB. SQFT. Date Recei t#
Z O NOTICETO APPLICANT:ILafter raking this Certificate of Exemption,you
should become subject to the Workeri Compensation provisions of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FE' Oil
IL 7 deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE N _
Il Iherebyaffirmthat there is a construction lending agency for the perform-
7 Z ance of the workforwhkhthis permit is blued(Sec 3097,CIv.q TOTAL: ELECTRIC FEE
.00
U O 1<naer.N.me PLUMBING FEE
U. L.enderspddmas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWIcertlfythatl)ave rcadthls appllutlonand katethattheabove information
IL Iscorren.I agree to comply with all city and county ordinances and slatefiws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representative of this
U) city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities,pelgreenu,mks and expenses which may In anyway same AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a auojAW6CAy inco scapi@F ran begotthie permit
L �• AIR HANDLING IIhTT(OVER 10,000C F) CONSTRUCTION TAX
Signature of pplicant/ mi ram r C e EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERTALSDISCI.OSURE
Will the appilunt or future budding occupant store or handle hazardous HEATING UNIT(10 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the �--/)
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: 67
❑Yea M No
Wllltheapplicant orfuturc building occupant use equipment or devices VENTILATION FAN(SINGLE READ) ISSP/gNfiWATE
which emit havrdoua air contamimnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4Yea 1��11 No
have read the haaamous materials mquimments underGhapter 6.95 of BOILER-COMP(OVER 100,000 BTL) MAY x 91951
the California Health&Safety Code,Sections 25505,25533 and 2534.1
understand that if the building does not currently have a tenant,that it ismy NEW RESIDENTIAL MEC#. SQ.Ff ^ sa ay N1
responsibility to notify the occupant of the requirements which must be met W,tV y' yuwno
prior to Issuance of a Certificate of Occupancy. 'I
OwneroruuthorizedaSent Date TOTAL: ISSUED
OFFICE COPY